Difficulty: Medium
Average Score: 64%
Simulated
A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?
Correct answer
C
Rationale
Profuse diaphoresis and a severe, pounding headache are hallmark signs of autonomic dysreflexia, which occurs in individuals with spinal cord injuries at or above T6 due to an exaggerated autonomic response to stimuli like a full bladder, causing severe hypertension and related symptoms.